Temperature
• Wash hands.
• Rinse thermometer in cold water if
kept in a disinfectant solution.
• Wipe dry with tissue moving from
bulb to stem using a firm twisting
motion
• Grasp thermometer with thumb and
forefinger and shake vigorously by
snapping wrist in downward motion
to lower mercury level to below 95-
960F (35.50C)
• Pat dry axilla of patient. Place
thermometer in the center of the
axilla and lower patient’s arm down
across the chest.
• Leave in place for 8-10 minutes.
• Remove thermometer and wipe it
once with tissue from fingers down
the bulb, using a firm twisting motion.
• Read temperature by rotating
thermometer until the mercury level
is clearly visible and at eye level.
Shake thermometer down, cleanse
and return to storage container.
• Dispose used tissue wipes in a
container for contaminated items
• Wash hands.
• Document temperature reading.
Pulse
• Assess the patient’s condition.
Determine the client’s activity
schedule.
• Place patient in a comfortable
position. Ask about activity within
the last half hour.
• Palpate over the pulsing artery
(radial or peripheral) using pads of
the three middle fingers.
• Apply light but firm pressure.
• Count pulse for one whole minute.
• Note rhythm and volume of the
pulse.
• Leave the patient in a comfortable
position.
• Document findings.
Taking an Apical Pulse
• Place the client in a supine or left-
sided position.
• Warm diaphragm with hands.
• Place stethoscope on the apex of
the heart. The apex is normally
located on the fifth intercostals
space just below the nipple and
three inches to the left of the
sternum.
• Count the rate for one minute when
taking an apical pulse.
• Assess rhythm and any unusual heart
sounds.
• Leave the client in a comfortable
position.
• Document findings.
Respirations
• Assess patient’s condition.
Determine the client’s activity
schedule.
• Place the patient in a comfortable
position. Lying down with the head
of the bed at 45-60o angle.
• Place a hand against the client’s
chest or position the patient’s arm
over the abdomen.
• While supposedly taking the radial
pulse, count respirations by
observing the rise and fall of the
patient’s chest for one whole
minute.
• Note rate, depth, rhythm, and
character.
• Document findings.
• Wash hands.
Blood Pressure
• Wash hands. Clean off the
stethoscope diaphragm or bell with
antiseptic wipes.
• Determine which extremity is most
appropriate for reading. Do not
take a blood pressure reading on an
injured or painful extremity or one in
which an intravenous line is running.
• Select a cuff size that completely • Continue to deflate cuff (sounds will
encircles the upper arm without change in quality). Record diastolic
overlapping. The bladder must BP as the sound disappears
encircle at least two-thirds of the (Korotkoff’s V sound). If sounds are
arm. continuously heard at a very low
• Explain procedure to the patient. reading, record the abrupt muffling
• Place the patient in a relaxed of sound, phase IV (muffling is often
reclining or sitting position with arm recorded for children)
at the level of the heart and with the • Release air from cuff after sound
palm of hand facing upward. ceases. Wait 2 minutes before
Expose the upper part of patient’s taking a second reading.
arm. Blood pressure should not be • Leave the patient in a comfortable
taken over clothes. position.
• Palpate the brachial artery. • Clean the diaphragm and bell of the
• Wrap cuff snugly and smoothly stethoscope with antiseptic wipes.
around the upper part of the arm Wash hands.
(about one inch above the • Record and report findings.
antecubital space) with the center
of the bladder over the brachial
artery.
• Place the gauge at eye level, close
enough to read. (Not more than
three feet away from the
manometer).
• Palpate the brachial artery, close
the valve and compress bulb to
inflate cuff to 30 mmHg above the
point where palpated pulse
disappears, then slowly release the
valve to deflate cuff.
• Place diaphragm or bell of
stethoscope on the medial
antecubital fossa where brachial
artery is felt.
• Place the stethoscope ear pieces in
your ears, tighten the screw valve
and inflate the cuff rapidly (7 sec or
less) by pumping up bulb until
manometer registers 30 mmHg
above the diminished pulse point or
at which pulsations are no longer
heard.
• Loosen valve slightly to release air at
a rate of 2-4 mmHg per second for
normal adult.
• Listen for a faint, clear tapping sound
that appears and increases in
intensity.